World Patient Safety Day

17 September 2024

World Patient Safety Day is an opportunity to raise public awareness and foster collaboration between patients, health workers, policymakers and health care leaders to improve patient safety. This year the theme is “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!”, highlighting the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes. WHO

UpToDate

• Fire safety in the operating room
• Infection prevention: General principles
• Infection prevention: Precautions for preventing transmission of infection
• Patient evaluation for metallic or electrical implants, devices, or foreign bodies before magnetic resonance imaging
• Patient safety in the operating room
• Prevention of adverse drug events in hospitals
• Prevention of perioperative medication errors
• Retained surgical sponge (gossypiboma) and other retained surgical items: Prevention and management
• Society guideline links: Patient safety in the operating room

Guidelines

• Incident management guide (Australian Commission on Safety and Quality in Healthcare)
• National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Healthcare)
• Patient safety and quality systems (Australian Commission on Safety and Quality in Healthcare)

Reports

• Admitted patient safety and quality (AIHW)
• Healthcare associated infections (Australian Commission on Safety and Quality in Healthcare)
• Healthcare safety and quality (AIHW)
• Hospital safety and quality (AIHW)
• Safety and quality reports (SA Health)

Articles

General hospital and healthcare safety

• Relationship between patient safety culture and patient experience in hospital settings: a scoping review
• Acute care nurses' decisions to recognise and respond to patient improvement: A qualitative study
• Strategies used to detect and mitigate system-related errors over time: A qualitative study in an Australian health district
• Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals
• Using machine learning models to predict falls in hospitalised adults
• The measurement of fatigue in clinicians within hospital settings: A systematic review of measurement properties
• Australian radiographer roles in the emergency department; evidence of regulatory compliance to improve patient safety – A narrative review
• Not just a ‘nice to have’: Team compassionate care behaviours and patient safety

Medication safety

• Prospective identification of medication harm in geriatric inpatients using a modified trigger tool
• Relationship between medication safety-related processes and medication use in residential aged care facilities
• Improving the quality of medication administration practices in a tertiary Australian hospital: a best practice implementation
• Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system
• Reasonable adjustments to application of the Medication Safety Standard for adult patients living with intellectual disability in Australian hospital settings

Surgical safety

• Unnecessary care in orthopaedic surgery
• Clinicians’ perceptions of “enhanced recovery after surgery” (ERAS) protocols to improve patient safety in surgery: a national survey from Australia
• Prevalence and risk factors associated within 48-hour unplanned paediatric intensive care unit readmissions: An integrative review
• The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey
• Implementation of a day-stay joint replacement pathway in an Australian regional public hospital: A descriptive study

E-books

• A sample of e-books available via the library catalogue

E-journals

• A sample of e-journals available via the library catalogue

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Articles

General hospital and healthcare safety

Relationship between patient safety culture and patient experience in hospital settings: a scoping review
The findings indicate that the patient can recognise safety-related issues that the hospital team may miss. However, studies mostly measured staff perspectives on patient safety culture and did not always include patient experiences of patient safety culture. Further, the relationship between patient safety culture and patient experience is generally identified as a statistical relationship, using quantitative methods. Further research assessing patient safety culture alongside patient experience is essential for providing a more comprehensive picture of safety. This will help to uncover issues and other factors that may have an indirect effect on patient safety culture and patient experience. BMC health services research 7 August 2024

Acute care nurses' decisions to recognise and respond to patient improvement: A qualitative study
What does this paper contribute to the wider global community?

• Acute care nurses’ frequent interaction with patients makes them well placed to recognise improvement.
• Objective and subjective cues are used by acute care nurses to recognise improvement in clinical states.
• Acute care nurses make decisions to respond to improvement based on their judgements of patient safety.

Journal of clinical nursing 6 August 2024

Strategies used to detect and mitigate system-related errors over time: A qualitative study in an Australian health district
Initial detection of system-related errors relies heavily on front-line clinicians, however other organisational strategies that are proactive and layered can improve the systemic detection, investigation, and management of errors. Together with Electronic medical record (EMR) design changes, complementary error mitigation strategies, including targeted staff education, can support safe EMR use and development. BMC health services research 14 July 2024

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals
The two main types of risks to patient safety described were related to clinical process/procedure and clinical administration. Commonly reported events included staff not following policy or protocol; doctors refusing to review a patient; and interruptions and inadequate information during handover. Our findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organizations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety. International journal for quality in healthcare 10 April 2024

Using machine learning models to predict falls in hospitalised adults
Highlights

• Falls in healthcare settings can result in significant patient harm and expense.
• Identification of patients at risk of falls is necessary for effective fall prevention initiatives.
• Information systems present an opportunity to analyse large quantities of data to inform fall prediction.
• In this study, patient, workforce and organisational characteristics data were included in machine learning models.
• Random forest and deep neural network models accurately predicted patient falls.

International journal of medical informatics 23 March 2024

The measurement of fatigue in clinicians within hospital settings: A systematic review of measurement properties
Medical staff fatigue leads to accidents and mistakes and puts patient safety at risk. A measure of fatigue in the workplace may help to quantify, predict, and manage fatigue. This review aimed to evaluate instruments used to measure fatigue in medical staff within hospitals. Nursing & health sciences 27 December 2023

Australian radiographer roles in the emergency department; evidence of regulatory compliance to improve patient safety – A narrative review
Patient safety in ED can be improved with timely and accurate diagnosis provided by radiographers. Radiographers have a professional obligation to adhere to the capabilities and standards for safe medical radiation practice defined by Australian regulations. Therefore, radiographers must justify the X-ray request, optimise the radiation dose where appropriate and communicate urgent or unexpected findings to the referrer. Radiography 20 December 2023

Not just a ‘nice to have’: Team compassionate care behaviours and patient safety
The experience of suffering is ubiquitous in healthcare facilities, but against this backdrop, is compassion a ‘nice to have’ or does it also affect patient safety? This article uses mixed methods across two studies to understand team compassionate care behaviours as a shared unit property and its association with patient safety outcomes. Using data from 188 healthcare teams, Study 1 finds that team compassionate care behaviours mediated the relationship between team psychological safety and fewer patient hospital-associated infections. Furthermore, the positive relationship between team psychological safety and team compassionate care behaviours was weakened when team workload demands were high. In Study 2, the authors interviewed 25 nurses to understand the experiences and gain further insights into the relationships between the focal variables. Together, our findings provide evidence that compassion emerges at the team level, is driven by team antecedents, moderated by team environments and tangibly affects patient safety. Australian journal of management 5 September 2024

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Medication safety

Prospective identification of medication harm in geriatric inpatients using a modified trigger tool
Medication harm (MH) causes patient morbidity and is a major healthcare burden. Research into MH is growing, but effective methods to identify MH are debated. The prevalence of MH is often based on an incomplete, retrospective chart review or spontaneous reporting, reliant on busy clinicians. A practical and clinically relevant method to detect MH is required. A trigger tool (TT) offers a solution. Journal of pharmacy practice and research 26 July 2024

Relationship between medication safety-related processes and medication use in residential aged care facilities
This study found that residential aged care facilities (RACFs) with a higher Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) tool score most likely have a lower proportion of residents with polypharmacy and benzodiazepines. A higher level of implementation of medication safety-related processes included in the MSSA-LTC tool may improve medication use in RACFs. Australian journal of ageing 24 June 2024

Improving the quality of medication administration practices in a tertiary Australian hospital: a best practice implementation
What is known about the topic?

• Medication administration is one of the most common causes of avoidable patient harm in the health care system worldwide.
• Medication administration errors are multifactorial and can include health care system flaws, human factors, or the underlying organizational culture. Contributing factors can include heavy workload, interruptions, disruptions, and multi-tasking.
• When performed judiciously, non-primed independent second checks may improve the safety of medication administration.

What does this paper add?

• A multimodal approach consisting of staff education, reminders, and facilitated discussions with staff, along with leadership commitment, feedback mechanisms, and support from internal and external facilitators, increased the performance of independent second checks and improved communication between nurses and patients.
• Strong drivers for cultural change include staff engagement in the development of action plans and locally relevant strategies for improving medication administration practices.
• A collaborative approach to quality improvement in medication administration was valuable in bringing different perspectives and experiences and led to comprehensive problem-solving and development of creative solutions to improve medication administration practices.

JBI Evidence Implementation 18 July 2024

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system
Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring. BMJ quality and safety 15 April 2024

Reasonable adjustments to application of the Medication Safety Standard for adult patients living with intellectual disability in Australian hospital settings
This review describes the formulation of a range of practice point reasonable adjustments to the usual clinical processes, content, knowledge, and organisation required in application of the Medication Safety Standard for adult patients living with intellectual disability. Journal of pharmacy practice and research 19 March 2024

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Surgical safety

Unnecessary care in orthopaedic surgery
Unnecessary care, where the potential for harm exceeds the potential for benefit, is widespread in medical care. Orthopaedic surgery is no exception. This has significant implications for patient safety and health care expenditure. This narrative review explores unnecessary care in orthopaedic surgery. ANZ journal of surgery 25 July 2024

Clinicians’ perceptions of “enhanced recovery after surgery” (ERAS) protocols to improve patient safety in surgery: a national survey from Australia
There is a need to promote Enhanced Recovery After Surgery (ERAS) and provide education, which may be nuanced based on the results, to improve implementation in Australia. Nurses particularly need to be engaged in ERAS protocols given their significant presence throughout the surgical journey. There is also a need to co-design implementation strategies with stakeholders that target identified facilitators and barriers, including lack of support from senior administration, managers and clinicians and resource constraints. Patient safety in surgery 23 May 2024

Prevalence and risk factors associated within 48-hour unplanned paediatric intensive care unit readmissions: An integrative review
This review acknowledges the complexity of confounding factors impacting unplanned paediatric intensive care unit (PICU) readmission and the lack of standardisation examining potential risk factors. The five modifiable factors are suggestive of clinical instability and premature PICU discharge. Patients with modifiable risk factors should have their readiness for discharge re-evaluated. Scaffolding support to manage patients at risk of readmission includes senior bedside nursing allocation, use of PICU outreach services, and 1:2 nurse-to-patient ratios in the ward setting, which are warranted to ensure patient safety. Australian critical care 9 May 2024

The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey
What does this paper contribute to the wider global community?

• The high prevalence of missed care in the operating room is related to communication practices and processes, which may compromise patient safety.
• The most common causes for lapses in care within the operating room were staffing-related issues, which had an adverse effect on teamwork.
• While there were no differences in the frequency of missed care related to nursing roles, there were statistically significant differences between nurse management, circulating/instrument nurses and recovery room nurses in reasons for missed care.

Journal of clinical nursing 21 February 2024

Implementation of a day-stay joint replacement pathway in an Australian regional public hospital: A descriptive study
The day-stay joint replacement surgery pathway was feasible to implement, safe and acceptable to patients. Day-stay pathways have potential patient and system-level efficiency benefits. The Australian journal of rural health 30 April 2024

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E-books

This is just a sample of the e-books the library subscribes to – you will need your library login

• Handbook of perioperative and procedural patient safety (2024)
• Principles of perioperative safety and efficiency (2024)
• Recent strategies in high risk surgery (2024)
• The nexus between nursing and patient safety (2024)
• Patient safety : a case-based innovative playbook for safer care (2023)
• Patient safety and risk management in medicine : from theory to practice (2023)
• Radiation safety in nuclear medicine : a practical, concise guide (2023)

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E-Journals

A sample of the journals the library subscribes to – you will need your library login

• Drug, healthcare and patient safety
• Joint Commission journal on quality and patient safety
• Journal of patient safety
• Patient safety
• Patient safety in surgery
• Patient safety monitor journal
• Pediatric quality & safety

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